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Dance/Movement Therapy (D/MT) 1 for Depression: A Scoping Review Abstract

Depression affects 121 million people worldwide (WHO 2010). The socio-economic

repercussions of depression are putting an enormous strain on UK and US governmental

health budgets. Regarding treatment interventions, D/MT and other arts therapies are

widely practiced around the world as a treatment of choice for depression. Research

evidence suggests that exercise has positive effects on mood. Similarly, it has been argued

that dance has a positive social-cultural influence on a person’s wellbeing. However there

are no systematic reviews that support the effectiveness of D/MT for people with a diagnosis

of depression.

It is therefore important to map the field existing research studies of D/MT for

depression. In this paper a scoping review is presented that engaged with an extensive

search to best answer the question: is there good quality research evidence available

regarding the effectiveness of D/MT and related fields for the treatment of depression? A

search strategy was developed to locate publications from electronic databases, websites,

arts therapies organizations and associations using specified criteria for including and

excluding studies. All studies meeting the inclusion criteria were then evaluated for their

quality, using broad criteria of quality such as type of methodology followed, number of

participants, relevance of interventions and specific comparisons made and outcome

measures.

1 In the UK and since 2008, the discipline is known as ‘dance movement psychotherapy’ and practitioners call themselves dance movement psychotherapists. For the purposes of this article the USA term ‘dance/movement therapy’ and its acronym ‘D/MT’ will be used throughout, while practitioners will be referred to as ‘dance/movement therapists’.

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A total of nine studies were found. Six studies followed a randomized controlled trial

design, and three adopted a non randomized design. At least one study met most criteria of

quality. We concluded that there was a need to undertake a full systematic review of the

literature and to follow a Cochrane Review protocol and procedures.

Keywords

Dance/Movement Therapy, Dance Movement Psychotherapy, Depression, Effectiveness,

Systematic Review, Randomized Controlled Trials

Introduction Dance/Movement Therapy (D/MT) and Evidence-Based Practice (EBP)

It is often difficult for arts therapists, including dance/movement therapists, who are not

in direct contact with academic institutions, to keep up to date with research evidence. As a

result of this, practitioners often become disconnected from recent developments, while

remaining reliant upon theoretical frameworks and their own and others’ experience to

inform their work. In recent years, however, dance/movement therapists, along with the

other arts therapists, are encouraged to shift towards a more cyclical process of practice

which on the one hand still remains well-informed by theory and experience but on the

other also draws upon research findings (Karkou 2009). This way research becomes an

integral part of practice informing clinical decisions throughout the therapeutic process.

Thorough evaluation of the therapeutic work and generation of research evidence based on

practice are also part of this cycle, aiming to develop improved services. Ultimately this

approach to practice highlights the value of research and makes it more tangible to the

working clinician. The framework for clinical practice that incorporates scientific research

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evidence is known as Evidence-Based Practice (EBP) (Mason, Leavitt, & Chaffee 2002,

Melnyk. & Fineout-Overholt 2005 and Leach 2006).

EBP requires a shift away from the traditional paradigm of clinical practice grounded

solely in intuition, clinical experience, and psychological rationale (Mason et al. 2002;

Melnyk. & Fineout-Overholt 2005, Leach 2006). Clinical expertise is seen as important in

combination with best scientific evidence, patient values and preferences, and clinical

circumstances. In Dance/Movement Therapy (D/MT) in particular, Meekums (2010) argues

that practitioners have at times tended to be misinformed and consequently demonize the

EBP paradigm. She suggests that there is a need for dance/movement therapists to embrace

research evidence including quantitative experimental studies while not losing sight of the

particular strengths offered through embodied knowledge. Our intention through this

scoping review is to offer this integration with respect to one particular area of evidence,

namely D/MT for depression.

In order to support the shift towards EBP, it is important that good quality research

evidence becomes available to practitioners. Systematic reviews and/or meta-analyses that

report on and evaluate research studies are often regarded as important sources of research

evidence in a particular area of clinical practice. However, there are not enough systematic

reviews and/or meta-analyses available to guide practitioners. Working with depression in

D/MT is one such area; while this is a common diagnosis for a number of clients seen by

dance/movement therapists, there is still a marked absence of either systematic reviews or

meta-analyses on the topic. This article, therefore, attempts to address the gap in the

literature by reporting on a scoping review of published and unpublished research studies

pertaining to the effectiveness of D/MT in the treatment of depression. The scoping review

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was an initial, step in order to determine whether we could undertake a systematic

Cochrane Review on the topic.

Systematic reviews aim to collate all empirical evidence relating to a specific research

question, using explicit, systematic and pre-determined methods in order to minimize bias

and generate reliable findings (Higgins and Green 2011). This kind of research activity is

often placed on the top level in the hierarchy of evidence (Eccles et al 2001). As a result,

systematic reviews, with or without meta-analyses, are highly respected by establishments

such as governmental bodies and national health systems. Some of the most respected

systematic reviews are undertaken by the Cochrane Collaboration. A Cochrane Review is a

systematic review that not only offers a summary of reliable evidence of the benefits and

risk of health care, but does this through a very clearly defined process and clearly defined

criteria. For a review to be called a Cochrane Review it needs to be part of the ‘parent

database’ (Cochrane Collaboration 2012 p.1) and to be linked with the Cochrane

Collaboration from the beginning to the end of this process.

In all cases and as a first step towards a systematic review, it is common for

researchers to undertake a scoping review. The purpose of a scoping review is to establish

the breadth of the field, key concepts and types of evidence, and what outcome measures

might be relevant; in effect, to ‘map’ it (Arksey and O’Malley 2005). For the scoping review

reported in this article, our intention has been to map the field of D/MT for depression.

Why Depression?

The World Health Organization (WHO 2010) reports that depression affects about 121

million people worldwide and is predicted to become in 2020 the second most disabling

illness in the world after ischemic heart disease. In the UK, national figures indicate a

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similarly large impact of depression on the general population. According to the 2000

Psychiatric Morbidity Report among adults living in private households, 8-12 percent of the

population is diagnosed with depression at some point in their lives (Office of National

Statistics 2000). The National Institute of Mental Health (NIMH 2010) in the US state that

9.5% of the population, which is approximately one in ten American adults, suffers from

depression. Scott and Dickey (2003), in their research on the global burden of depression,

suggest of those who suffer major depressive disorders 20% will have symptoms that persist

beyond two years of the initial diagnosis and treatment. Whichever estimates are accepted,

depression clearly represents a significant burden to families and to society; it has a negative

impact on quality of life, and can lead to suicide. For example, more than 90% of Americans

who take their own lives have an undiagnosed mental health disorder or a continual

depressive disorder (NIMH 2005, & Scott and Dickey, 2003), Often depression goes

undiagnosed; hence the real scale of the problem is probably much larger than that

identified by national statistics.

Departments of Health in the UK and US acknowledge that only a few sufferers receive

treatment. For example, the USA Department of Health and Human Services (2011) reports

that only one in five adult sufferers receive adequate treatment in accordance to guidelines

set by the American Psychiatric Association (APA) (2012); even fewer receive treatment

amongst ethnic minority groups (Arean 2011)). In the UK, The Depression Report by The

centre for Economic Performance’s Mental Health Policy Group (2006) claims that two in six

people who do not receive treatment could be “cured at a cost of 750 pounds” (p4). The

focus of the report is one of economic cost and reduction of Incapacity benefits. It suggests

that depression is the biggest social problem and number one cause of unemployment

affecting 40% of people claiming Incapacity benefits in the UK, (The Center for Economic

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Performance’s Mental Health Policy Group 2006). Major depression is a feature of 22% of

Americans who classify themselves as unable to work and 10% of those who are already

unemployed (Centers for Disease Control and Prevention, CDC 2010). The cost of depression,

the loss of productivity and medical expenses is $83 billion in the USA (Leahy 2010) in

comparison to the £12 billion a year for the UK Government (The Center for Economic

Performance’s Mental Health Policy Group 2006), an enormous cost to the government but

perhaps an even greater cost to the individual who on average decrease their lifetime

earning potential by 35% due to undiagnosed and untreated depression (Leahy 2010).

Between 1991 and 2002 in the UK alone, prescriptions per head for anti-depressants

increased by £310 million (Medical News Today 2005). In the USA the overall costs for

outpatient treatment of depression increased from $10 billion in 1997 to $125 billion in 2007

(Zorumski and Rubin 2011), a point which illustrates the sheer expense of the

pharmaceutical management of medication. Zorumski and Rubin (2011) state that there is

potential to curb the costs if physicians were to prescribe less inexpensive and more generic

anti-depressants and consider other evidenced-based psychotherapies rather than be

concerned with prescription privileges. The London Center of Economic Performance’s

Mental Health Policy Group (2006) proposes a new nationwide therapy service to be put in

place to counter-balance the billions of pounds lost through inactivity. The loss, when

compared to the £0.6 billion it would cost to provide an effective therapy service in the UK,

surely justifies the importance of therapeutic interventions for depression. The argument

that remains is that a therapy service is only justified if it is effective enough in making

people feel better, and enabling them back to work.

In terms of UK health policy, the last decade has seen an expansion of psychological

treatments for common mental health problems. The general consensus according to both

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English and Scottish governments is that attitudes toward mental health, especially

depression, should be less about reaction and more about prevention (The Department of

Health, 2008; The Scottish Government 2008). Governmental targets emphasize an

approach towards mental health based on a social model which recognizes that healthy

mental capacity is shaped by social, cultural and economic environments. In contrast, in the

USA there does not appear to be a single governmental incentive, mainly due to the complex

infrastructure of the health care system; many different providers, treatment settings and

payment mechanisms (Sundararaman 2009). Congress policies under discussion focus

heavily upon practical issues related to mental health such as access in rural areas, co-

ordination between providers, comprehensive health insurance cover and better evaluation

measures of the quality of mental health care (Sundararaman 2009). Research conducted

through the NIMH (2010) is largely focused on the connectivity of neuronal and biochemical

processes in the brain that explains the symptoms and behavior of depression. As a result, it

appears that US treatment has a more medical focus in comparison to the social focus in the

UK and is thus much more interested in the development of pharmaceuticals and the

adherence and continuous use of anti-depressants (NIMH 2010)).

In the UK, the shift away from a model of treatment heavily reliant on medication and

towards a more holistic approach indicates the need for evidence relating to a range of

psychological therapies. English targets, which initially prioritized Cognitive Behavioral

Therapy (CBT) as the main intervention, nevertheless enshrine the intention of including the

wider range of therapies approved by UK-based treatment decision bodies (National

Institute of Clinical Excellence, NICE 2009 and Scottish Intercollegiate Guidelines Network,

SIGN 2010). A review of the evidence relating to D/MT for depression is thus timely.

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Dance/Movement Therapy (D/MT) and Depression: The Evidence So Far

D/MT is widely practiced around the world often with people who are suffering from

depression, whether or not depression is diagnosed. There are no systematic reviews on the

effectiveness of D/MT for depression. There is, however, a relatively large body of

knowledge that relate to exercise and the effects of exercise on mood. Furthermore,

overviews of the effects of exercise on depression can be found as early as 1988. In a meta-

analysis by Craft and Lander (1988) movement was seen as having beneficial effects on

depressive symptoms. More recently, a range of publications have reported on the

effectiveness of exercise on depression. However, the validity of their conclusions has been

hampered by methodological problems and lack of follow up studies (Sjosten and Kivela

2005, Lawlor and Hopker 2001, Dimeo et al 2001). Mead et al (2008), in their study to

determine the effectiveness of exercise as a treatment for depression, call for more robust

research that describes the type, frequency and intensity of the form of exercise used in the

trial. Bradshaw, Lovell and Hams (2005) insist that specific client groups within specific

settings should be defined in all systematic reviews. For example, particular attention needs

to be paid to levels and etiology of depression for older age groups. Physical problems and

isolation are particular risk factors for the development of depressive symptoms in people

aged between 60 and 74 (Kerse et al 2008, Williams and Tappen 2007, Sjosten and Kivela

2005).

Furthermore, evidence suggests that exercise can lead to short-term mood improvement

(Williams and Tappen 2007, Sjosten and Kivela 2005, Dimeo et al 2001), but there is no

evidence of significant long-term effects. There is a need for long-term studies of the effects

of exercise on depression, involving larger groups (Kerse et al 2008, Mead et al 2008,

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Williams and Tappen 2007, Sjosten and Kivela 2005, Dimeo et al 2001, Lawlor and Hopker

2001).

If exercise programs can be assumed to improve strength, endurance, and body

mechanics and possibly alter mood states, dance may have all of these effects but also has

the potential pleasure from creating dance movement and the added dimension of social

interaction. A growing body of research literature exists concerning the socio-cultural

communication encouraged by participating in dance which brings groups of people

together in a ‘team spirit’. According to more current qualitative studies using dance as a

parameter to assess well-being and psychological states in the older person, the focus is on

the ritualistic or folkloric aspects of the dance (Hui, Chui and Woo 2008, Belza et al 2004).

Belza et al (2004) for example, recruited 71 older adults through community agencies to

participate in seven ethnic-specific focus groups: American Indian/Alaska Native, African

American, Filipino, Chinese, Latino, Korean, and Vietnamese. Their results demonstrated

that participants’ perception of improvement of depressive symptoms (e.g. fatigue, negative

thoughts) was such to warrant the development of a country-specific folkloric dance

program that aimed to enable older people to sustain independence and move away from

isolation.

D/MT and other arts therapies are used extensively in the treatment of depressive

symptoms with client groups whose main diagnosis may be anxiety, obesity, medically

unexplained conditions or behavioral difficulties (Brauninger 2006, Payne 2009, Vaverniece,

Dusele and Meekums in preparation, Karkou, Fullarton and Scarth 2010). Yet there is limited

quantitative evidence that supports their effectiveness of D/MT with people with a diagnosis

of depression. It is possible that D/MT offers added value over both exercise treatments and

dance classes in that it encompasses an embodied therapeutic relationship. Stiles, Barkham

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Mellor-Clark et al’s (2007) study on the comparative effectiveness between different

therapies (CBT, person centered therapy and psychodynamic psychotherapy), found that

despite having non-equivalent theories and techniques, the outcomes were equivalent. They

express this paradox as the ‘dodo bird verdict’ (Rosenzweig, 1936, cited in Luborsky et al,

2002, p. 2). This proposition is supported by Luborsky et al’s (2002) review of meta-analyses;

‘Everybody has won and all must have prizes’ (taken from Lewis Carroll’s Alice’s Adventures

in Wonderland). The dodo bird verdict suggests that a large part of the therapeutic effects of

any psychotherapy is due to common factors and in particular the therapeutic relationship,

regardless of the therapeutic framework of the therapist (Stiles et al, 2007). In the context of

arts therapies, qualitative research by Meekums (1999) suggests that one important factor in

the therapeutic relationship is the client’s sense of psychological safety, the presence of

which acts like a catalyst for positive change while the absence of psychological safety acts

like a malevolent presence, associated with deterioration in mental state. Despite this

important finding, we have found no valid and reliable measures for the therapeutic

relationship incorporating the client’s sense of safety, other than in studies in family therapy

(Friedlander et al, 2006).

Notwithstanding the evidence for common factors influencing psychotherapeutic

outcome, there is a wealth of well-designed research studies concerning the effectiveness of

CBT on depression. However, most of these studies do not compare CBT to other therapies

but to waiting list controls. This may add a degree of bias to the results, since arguably any

therapy is better than no therapy, provided that ‘common factors’ are met. It is perhaps not

surprising, given the plethora of randomized controlled trials of CBT, that the potential value

of D/MT has been overlooked. This is often associated with the degree to which D/MT is

taken seriously enough to invest time and money on a substantial piece of research work.

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Furthermore, one could question the degree to which a randomized controlled trial, the

golden standard of investigating medical treatments, is indeed the best possible research

design for psychotherapeutic interventions. Unlike CBT, D/MT, as a form of humanistic or

psychodynamically-informed practice, does not follow a standardized mode of delivery and a

fixed clinical protocol. In including a control group, there is a similar assumption that

variables will be controlled and thus interventions will be compared without interference

from other variables. The concept of randomization in itself can also be questioned; in

regular D/MT clinical practice selection of members for a group requires careful

consideration of group therapy criteria such as ‘best fit’, since this may offer the best

prognosis. If this principle is not adhered to and instead people are randomly allocated to

either D/MT or a control group, positive treatment outcomes can be jeopardized.

It appears that either because prejudiced views of dance as ‘not serious’ remain or

because randomized controlled trials, the golden standard of quantitative designs, are not

seen as readily fitting D/MT practice, a ‘chicken and egg’ situation has developed: there is

limited evidence of effectiveness which in turn leads to underfunding of research in this area

(Meekums 2010 & 2006, Koch et al 2007, Karkou and Sanderson 2006).

The one meta-analysis completed in the field by Ritter and Low (1996) that was

recalculated by Cruz and Sabers (1998) provides evidence for the effectiveness of D/MT with

clients suffering a wide array of symptoms. However, the study does not examine studies

for one particular diagnostic category and has not been updated since 1998 (at the time of

finalizing this paper, an update is underway, conducted by Koch and colleagues). Karkou and

Sanderson (2006), in their review of arts therapies research, conclude that research registers

held with professional associations and/or completed by researchers in the field include very

few systematic examinations of research evidence with people facing depression. This

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seems to be true for research evidence concerning D/MT for any single diagnostic category.

Consequently there are only a few available Cochrane Reviews in D/MT which include only a

limited number of studies. For example, the Cochrane Review of dance therapy for

schizophrenia (Xia & Grant, 2009) found only one study that was of a sufficiently high quality

to include in the review i.e. the study by Rohrich & Priebe (2006) that provided evidence for

the positive effects of D/MT on the negative symptoms of schizophrenia. Still, this seemed

to be sufficient to result to the inclusion of D/MT in the NICE guideline for schizophrenia as a

recommended treatment option and thus to support the development of relevant D/MT

services in the UK. The most recent systematic Cochrane Review of D/MT evidence for

cancer care (Bradt, Goodill and Dileo 2011) provides evidence or the value of D/MT for

improving the quality of life of participants and decreasing fatigue. The number of studies in

D/MT for cancer care that met Cochrane standards was equally small; only two studies were

finally included in the review providing positive but, given the small number of participants,

inconclusive results.

Regarding systematic reviews available for depression in the other arts therapies, a

Cochrane Review completed by Maratos et al (2009) found music therapy to be a viable

treatment for depression; evidence was drawn from a small number of studies. Maratos et al

(2009) suggest that music therapy is associated with short-term mood improvement, and is

different to standard care in that it is well tolerated by the subjects. However, conclusions

remain rather similar to the Cochrane Review of dance therapy for schizophrenia (Xia &

Grant, 2009) in that the effectiveness of music therapy on depression was unclear due

largely to a lack of methodologically sound studies in the field. As yet, Cochrane Reviews for

depression are not available in any of the other arts therapies including D/MT.

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Methodology for this scoping review

The scoping review reported in this paper was carried out over a period of three months;

May, June and July 2009, which was reviewed again in November 2010 in preparation for the

title approved by the Cochrane Collaboration ‘Dance Movement Therapy for Depression’

(Meekums, Karkou, Nundy-Mala, Elefant and Nelson 2010). As a scoping exercise it

remained fairly wide, searching for research studies that could best answer the question:

Is there good quality research evidence available regarding the effectiveness of D/MT and

related fields for treatment of depression?

By ‘good quality’ we drew upon the hierarchy of evidence (Eccles et al 2001; Higgins 2009)

as used by the Cochrane Collaboration. And we defined ‘related fields’ to stand for the other

arts therapies (art, drama and music) and dance.

The process of undertaking the scoping review involved the following stages:

The development of a search strategy that involved searching for research

publications located in a wide range of electronic databases, websites, arts therapies

associations and organizations (led by the first author with contributions by the other

two).

Sourcing publications and evaluation of quality (all three authors).

Consultation and agreement amongst team members on the inclusion or exclusion of

publications and their quality on the basis of agreed criteria (all three authors).

Writing up (all three authors).

Development of Search Strategy

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Research evidence was identified by conducting searches across bibliographical databases

with pre-determined search terms. Table A shows how this strategy translated to reflect the

various indexing terms, search functions and syntax available on the specified databases.

[Table A: The Search Strategy around here]

A search for evidence based exclusively on electronic databases would have overlooked

relevant publications. To widen the search, the same indexing terms, syntax and search

combinations were also used in the following areas:

1. Specific Electronic Journals: Body, Movement and Dance in Psychotherapy; E-Motion;

The Arts in Psychotherapy; American Journal of Dance Therapy; British Journal of

Guidance and Counseling; Counseling and Psychotherapy Research; European Journal

of Psychotherapy; Counseling and Health.

2. Arts Therapies Websites and Online Research Registers: Electronic databases held

with the Association for Dance Movement Psychotherapy UK (ADMP UK); the

American Dance Therapy Association (ADTA); and the Dance-Movement Therapy

Association of Australia (DTAA). The European Register was checked and found to be

under construction at the time of the search; instead the German Research Register

was included.

3. Generic Search Engines; Google.com; Google Scholar; Live Search; Yahoo

4. Reference Lists; the reference lists of all seminal publications obtained were checked

in order to identify additional references. Although an effective process of checking

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for additional publications, if a reference was found to be important it was also

searched for within the bibliographical databases.

Inclusion and Exclusion Criteria

Research studies were identified using the search strategy shown in Table A. Inclusion

criteria used to specify studies were: randomized controlled trials, controlled trials,

experiments and quasi-experimental studies; published and unpublished; in English; either

as whole papers or as abstracts; which stated outcomes specific to the effectiveness of

D/MT, arts therapies and dance as interventions for depression.

Exclusion criteria were: all studies that were not methodologically robust; studies which

did not provide results and discussion about findings. We also excluded studies relating to

exercise due to the fact that this field is extensively researched and reviewed. Studies

relating to D/MT, arts therapies or dance used for alleviation of depressive symptoms were

also excluded in order to identify evidence for D/MT for clients with a diagnosis of

depression rather than depression as a co-morbid illness.

Table B shows an example of how the literature was searched. The table includes

information on databases, dates of when the search took place, search terms used, the total

number of articles and relevant articles found.

[Table B: Examples of Literature Searches around here]

An initial evaluation of the quality of the sourced studies was then completed using the

following criteria as stated in the application for to the Cochrane Collaboration for the

systematic review of D/MT for depression (Meekums et al 2010):

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1. Types of study

2. Participants

3. Interventions and specific comparisons made

4. Types of D/MT interventions and comparisons with other therapies

5. Outcome measures used

Note that as this was a scoping exercise aiming to answer the study = question, ie whether

there were good quality research studies available in the treatment of D/MP and related

areas for depression, statistical analysis of data from the collected studies was not

undertaken.

Findings and Discussion

We found a total of 9 studies which fulfilled at least one of the inclusion criteria.

[Table C: Findings around here]

Of the nine studies found, six studies followed a randomized controlled trial design, and

three adopted a non randomized design.

Non Randomized Controlled Trials

Three studies are included in Table C because they are significant pieces of research

which offer a wider picture of existing literature in the field of D/MT and depression, arts

therapies and depression, and dance and depression. None of the three were randomized

controlled trials, but followed either a controlled trial design or a design with pre and post

testing.

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Alpert et al (2009) and Jeon et al (2005) both focused on dance for older people living

with depression, either jazz dance (Alpert et al 2009), or traditional Korean dance (Jeon et al

2005). Alpert et al (2009) used a quasi-experiment design to evaluate the impact of class

instructed jazz dance on the balance, cognition and mood of older women. The study used a

time series analysis of self-reported questionnaires completed by the participant during

three time intervals, without a random assignment. Comparisons were made between jazz

dance participation and the dependant variable outcome from the three time intervals. On

the other hand, the study by Jeon et al (2005) is the methodologically stronger of the two

studies. It followed a quasi-experiment design that was strengthened by the use of a

controlled trial with a large sample of 130 subjects in the intervention group and 123 in the

control group. The level of depression was just one of the features tested in both studies

alongside balance, medical cost, medical institutions utilization, and falls (Jeon et al 2005)

and balance, cognition and mood (Alpert et al 2009). Outcomes for both studies were

favorable for dance and highlight improvements especially in balance which according to

Alpert et al (2009) was attributed to the preventions of falls, one of the major causes of

morbidity in the older adult (Alpert el al 2009). However no direct link could be made

between dance and improvement of mood.

Harden’s (1989) doctoral study is categorized under studies of D/MT for clients faced with

depression (see Table C). Harden (1989) reported on a quasi-experimental pre and post

testing design that had a twofold aim: (a) to examine the effect of group movement therapy

on depression, morale and self-esteem; and (b) to identify any relationships between certain

demographic variables and depression, morale, and self-esteem in women aged 65 and

above who resided in four intermediate day care facility nursing homes. Four groups, one in

each care facility, were set up to test four hypothesized outcomes: (a) lower depression, (b)

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higher morale, (c) higher behavior morale, and (d) higher self esteem. Findings of these

hypotheses showed significant differences among the four groups. The movement therapy

group; showed a significant change in pre to post test scores, demonstrating improvement

of depression, higher behavior morale and higher self esteem in comparison to other study

groups. Although the authors found a link between group movement therapy and the

improvement of well being among older people, the lack of a control group does not allow

for clear conclusions to be drawn from the findings. This is not to say the study is not worthy

of merit, but outcomes may be difficult to determine due to the particular intervention used,

the tests employed and a variety of extraneous variables affecting successful therapeutic

interventions.

Randomized Controlled Trials

Our literature search revealed that there are some interesting studies with rigorous

scientific design on dance for clients faced with depression (Table C). The first was by Eyigor

et al (2009) who completed a randomized controlled trial focusing on Quality of Life (QoL) of

older people. The second, completed by Koch et al (2007), followed an experimental design

that identified a particular dance-related aspect of D/MT with psychiatric patients with

depression.

Eyigor et al (2009) used Turkish folkloric dance as an intervention to affect the

physical capabilities of the subjects, indirectly aiming to make changes in their depression.

Volunteers were recruited through advertisement and formed two groups; (a) a folkloric

dance based group, (b) a control group that continued with their daily activities pre-study.

Eyigor et al (2009) used three outcome measures: (i) Berg balance Scale (BBS), which looked

at physical functionality; (ii) Medical Outcomes Study (MOS), a health survey; and (iii)

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Geriatric Depression Scale (GSD) questionnaires. The evaluation of GSD questionnaires

showed no significant changes in the clients’ depression; however the researchers state that

half of the participants were evaluated as ‘normal’ pre-study on the basis of the GSD scale.

Koch et al (2007) focused on a particular aspect of D/MT practice with psychiatric

patients with depression, investigating the role of the ‘jumping rhythm’ in circle dance. Koch

et al (2007) formed three group conditions: (a) Israeli circle dance group (which uses both a

circular group formation and movements characterized by strong ‘Weight’); (b) a group that

listened to just the music associated with Israeli dance; and (c) a group that moved at home

on an ergometer (home trainer). All thirty one participants of the study were diagnosed

with depression using ICD 10 as a measure to ascertain either a main or additional diagnosis

of depression. The study used a 12 item scale inventory, the Heidelberg State Inventory

(HBS), (Koch et al 2007), as a pre and post test means. Results were in contrast to Eyigor et

al’s (2009) study, Koch et al (2007) findings from the HBS inventory scale showed a

significant decrease in depression and increased vitality in the group that used circle dance

as an intervention; the group who moved on an ergometer showed less than that of the

intervention group but more than the group that just listened to music. The difference

between the two studies can possibly be attributed to the fact that the participants for the

second study had been selected to form a cohesive group on the baseline measurement; all

were diagnosed with depression.

Erkkila et al (2008) and Wu, Shwu Ming and I-Shou, (2002), were found to be the main

randomized controlled trials representing arts therapies with clients faced with depression.

Both studies focused on music therapy as the intervention; for the treatment of depression

(Erkkila et al 2008), and on depression, anxiety and self esteem (Wu Shwu Ming and I-Shou,

(2002). Both studies offered very clear descriptions of the designs of the trials, the measures

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used and the outcomes obtained; the main difference was in the size of the study. Erkkila et

al’s (2008) study involved 85 participants between 18-50, with severe depression as assessed

by the Mini-SCID, a structured clinical interview for DSM-III R (Erkkila et al 2008; Grunenberg,

Goldstein and Pincus 2005). All participants received standard care and the experimental

groups also received improvisational music therapy twice a week as the intervention. Wu

Shwu Ming and I-Shou, (2002) described a smaller trial using 24 undergraduate students as

subjects who were randomly assigned to a treatment group of music therapy and a control

group with no intervention. Both studies were robust in their evaluation of the outcomes of

the trial. Erkkila et al (2008) looked at both primary and secondary outcomes, and offered

details of the measures used: the Montgomery and Asberg Depression Scale (MADRS) was

used to measure primary outcomes. Findings from the Wu Shwu Ming and I-Shou (2002)

study revealed that there was a reduction in depression in the experimental group only after

a two-month follow up, whereas the level of anxiety showed immediate improvement after

the music therapy intervention.

Steward et al (1994) and Joeng et al (2005) are the strongest studies of D/MT for clients

faced with depression; both used a defined type of D/MT and both adopted a randomized

controlled trial design. In particular, Steward et al (1994) applied a crossover design for

inpatients with depression. Twelve participants were selected from their inpatient records to

see if they fitted the criteria for depression using psychiatric diagnosis (DSM-III-R) and by an

interview conducted by a trained nurse using the Diagnostic Interview Schedule. Movement

therapy was randomly assigned for seven days of the 14-day study. On the other seven days

a non movement therapy condition was applied. The evaluation measure used was the

Depression Adjectives Check List (DACL), in which the subjects chose adjectives that best

21

described their feeling on both the intervention and non intervention days. Critiquing this

study, two comments can be made:

(i) This study was completed by nurses; their understanding of what they called

movement therapy was limited to the medical model and the use of movement

work resembled daily exercise and/or medication. Therefore there were neither

references made to the therapeutic relationship nor to the embodied therapeutic

relationship in particular as discussed by Meekums (2002). No references were

made either to the overall therapeutic approach used in the intervention as

described by Karkou and Sanderson (2006).

(ii) The design appeared to be unnecessarily complex, and the sample was small.

Nevertheless, the outcomes showed significant reduction in depressed mood on the

intervention days in five of the 12 subjects. None of the subjects had significant results in the

opposite direction, while seven subjects showed no change in mood.

Jeong et al (2005) randomly assigned 40 student adolescents (mean age; 16 years old)

with mild depression to either group D/MT or a no intervention control group. The intention

of the study was to examine and track changes in the neurohormones linked to depression.

Thorough depression measurements were employed: BDI (Becks Depression Inventory), to

initially indentify subjects; and SCL-90.R (Symptom Check List-90-Revision), to assess

psychological distress and interpersonal sensitivity. Lastly liquid chromatography with

electrochemical detection was used to measure the concentration of plasma, serotonin and

dopamine in the individual (Joeng et al 2005). A 12 week D/MT program ran three times a

week, and was designed around four major themes: awareness; expression and symbolic

quality; images and feelings; and the differentiation and integration of feelings (Joeng et al

2005). Results showed significantly increased plasma serotonin concentration and decreased

22

dopamine concentration, and found that the negative psychological symptoms of distress

had improved in the treatment group, but not in the control group. There is clear evidence

to suggest that that the modulation of serotonin and dopamine production through the

intervention of D/MT might be a mechanism for reduction in depression.

Conclusions

Going back to the research question guiding this scoping review (i.e. ‘is there good quality

research evidence available regarding the effectiveness of D/MT and related fields for

treatment of depression?’), we found a number of studies in D/MT and related fields for

depression that met our inclusion criteria. They were evaluated in the first instance using

broad criteria of quality such as the presence or absence of full randomization, allocation of

participants in two groups and the completion of comparisons of D/MT with either a waiting

list, standard care, music alone etc through standardized tests. From the reviewed studies

there is at least one study that meets most criteria of quality and addresses the D/MT

discipline per se, that of Jeong et al (2005). Further studies of a similar quality might be

identified through a longer and more exhaustive search of published and grey literature.

Given that randomization is a difficult process in therapeutic work, quasi-experimental

studies may also need to be considered. Further arguments will need to be made to the

value of well-designed and thorough quasi-experiments. Berrol (2012) notes that when

dealing with human subjects, the reality is, because so many of the variables cannot be

controlled, most studies fall into the category of quasi-experimental research. When quasi-

experimentation takes place “the investigator not only needs to be aware of, but also work

within the constraints of this modified form, (Berrol 2012, p.??)

23

Nevertheless, this scoping review suggests that there are a growing number of scientific

studies in D/MT and related fields. It has therefore become essential to pursue a more

systematic review of the literature through completing a Cochrane Review on the topic. The

growth of depression as a global burden (WHO 2010) is an additional reason for the need to

tackle issues of effectiveness as defined by the medical and health professions, and policy

makers. And as Meekums (2010) has argued elsewhere, as dance/movement therapists we

need to start changing our attitudes towards research, shifting away from a defensive

tendency within the profession to demonize the scientific paradigm. Developing a more

systematic body of scientific evidence can improve our chances to capitalize on what we

already know in our practice as effective. Furthermore, as both Karkou (2009) and Meekums

(2010) have argued, we need to engage in a dialogue with scientists and form research

teams that can generate robust and effective research evidence.

Acknowledgements

We wish to acknowledge the financial support of pump prime funding from the School of

Healthcare, University of Leeds UK., and Queen Margaret University, Edinburgh for the use

of their Learning Resource Centre.

References

Alpert, P.T., Miller, S.K., Wallmann, H., Harvey, R., Cross, C., Chevalia, T., Gills, C.B, & Kodandapari , . (2009). The effect of modified jazz dance on balance, cognition and mood in older adults. Journal of the American Academy of Nurse Practitioners; 21, 108-115 American Psychological Association (APA) (2012). Available online: http://www.apa.org/about/division/activities/guidelines.aspx Arean, P. A. (2011) Mental Health Service use of disparities in low-income, ethnic-minority, older adults. Available online: http://www.apa.org/about/gr/issues/aging/arean-briefing.pdf

24

Arksey, H., & O’Malley, L. (2005). Scoping studies: towards a methodological framework. International Journal of Social Research Methodology; 8 (1). 19-32. Belza, B., Walwick, J., Shiu-Thornton, S., Schwartz, Taylor. M., & LoGerfo. J. (2004). Older adult perspectives on physical activity and exercise: voice from multiple cultures. Preventing Chronic Disease; public health research, practice and policy. 1, (4) Berrol C (2012) The expanding options of experimental research in dance movement therapy in Cruz, R. F., & Berrol, C. F. (Eds.). (2012, 2nd edition). Dance/movement therapists in action: A working guide to research options. Springfield, Ill: Charles C Thomas, pp.23-44 Bradshaw, T., Lovell, K., & Hams, N. (2005). Healthy Living Interventions and Schizophrenia. Journal of Advanced Nursing; 49(6), 634-654. Bradt, J., Goodill, S. & Dileo, C. Dance movement therapy for improving psychological and physical outcomes in cancer patients (Review). Cochrane Database of Systematic Reviews 2011; Issue 10. Art. No. CD007103. DOI: 10.1002/14651858.CD007103.pub2. Brauninger, I. (2006). Treatment modalities and self-expectancy of therapists: modes, self-efficacy and imagination of clients in dance movement therapy. Body, Movement and Dance in Psychotherap;, 1(2); 95-114. Centre for Disease Control and Prevention (CDC), (2010). Available online: www.cdc.gov/ Cochrane Collaboration (2012) Cochrane Reviews. Accessed 02 03 12 Available online:: http://www.cochrane.org/cochrane-reviews Craft, E. L., & Landers. D. M. (1988). The effects of exercise on clinical depression and depression resulting from mental illness: A Meta-analysis. Journal of Sport and Exercise Psychology; 20, 339-357 Cruz, R., & Saber. D. (1998). Dance/Movement Therapy is more effective than previously reported. Arts in Psychotherapy; 25(2), 101-104. Dimeo, F., Bauer, M., Varahram, I., Proest, G., & Halter, H. (2001). Benefits from aerobic exercise in patients with major depression: a pilot study. The British Journal of Sports and Medicine.; 35, 114-117 Eccels, M., Freemantle, N., & Mason, J. (2001). Using Systematic Reviews in Clinical Guideline Development. In M. Egger, G, D. Smith & D.G, Atman (Eds), Systematic Reviews in Health Care: Meta-analysis in Context (pp 400-418) London: British Medical Journal Books. Erkkila, J., Gold, C., Fachner, J., Ala-Ruona, E., Punkanen, M., & Vanhala, M. (2008). The effect of improvisational music therapy on the treatment of depression: protocol for a randomized controlled trial. BMC Psychiatry; 8(50).

25

Eyigor, S., Karapolat, H., Durmaz, B., Ibisoglu, U., & Cakir, S. (2009). A randomized controlled of Turkish Folklore dance on the physical performance, balance, depression and quality of life in older women. Archives of Gerontology and Geriatrics; 48, 84-88 Friedlander, M. L., Escudero, V., Horvath, A., Heatherington, L., Cabero, A., & Martens, MP. (2006). System for observing family therapy alliances: a tool for research and practice. Journal of Counseling Psychology; 53 (2), 214-224. Grunenberg, A. M., Goldstein, R. D., & Pincus, H. A. (2005). Classification of Depression: research and diagnostic criteria (DSM-IV and ICD-10). In J. Licinio, & Wong. M. (Eds), Biology of Depression, from novel insights to therapeutic strategies. WILEY_VCH Verlang GmbH & Co KGaA: Weinheim Harden, J. (1989). Effect of movement group therapy on depression, morale and self-esteem in aged women. Doctoral dissertation; University of Texas at Austin. Higgins, JPT., & Green. S (Eds) (2011). Cochrane Handbook for Systematic Review of Interventions. Version 5.0.2 [updated September 2011]. The Cochrane Collaboration. Available online; www.cochrane-handbook.org. Hui, E., Chui, B. T., & Woo. J. (2008). Effects of dance on physical and psychological well-being in older persons. Archive of Gerontology and Geriatrics; 49 (1), 45-50. Jeon, M. Y., Bark, E. S., Lee, E. G., Im, J. S., Jeong, B. S., & Choe E.S. (2005). The effects of a Korean traditional dance movement programme in elderly women. Taehan Kanho Hakhoe Chi; 35(7), 1268-76 Jeong, Y. J., Hong, S. C., Lee, M. S., & Park, M. (2005). Dance Movement Therapy improves emotional responses and modulates neurohormones in adolescents with mild depression. Intern, J. Neuroscience; 115, 1711-1720. Karkou, V. (2009). Evidence Based Practice and Practice Based Evidence in Arts Therapies. Keynote speech at the 7th international arts therapies conference Contemporary Arts Therapies – Theory and Practice; 17-19/07/09, Riga Stradins University, Cesis, Latvia. Karkou, V. & Sanderson, P. (2006). Arts Therapies; A research-based map of the field. Edinburgh: Elsevier. Karkou, V., Fullarton, A., Scarth, S. (2010). Finding a Way out of the Labyrinth through Dance Movement Psychotherapy: Collaborative Work in a Mental Health Promotion Programme for Secondary Schools, in V. Karkou (Ed) Arts Therapies in Schools: Research and Practice. London: Jessica Kingsley; pp. 59-84. Kerse, N., Falloon, K., Moyes, S. A., Hayman, K. J., Dowell, T., Kolt, G. S., Elley, R. C., Hatcher, S., Peri, K., Keeling, S., Robinson, E., Parsons, J., Wiles, J., & Arroll, B. (2008). DeLLITE

26

Depression in late life: an intervention trial of exercise. Design and recruitment of a randomized controlled trial. BMC Geriatrics; 8(12) Koch, S., Morlinghaus, K., & Fuchs, T. (2007). The joy of dance specific effects of a single dance intervention on psychiatric patients with depression. The Arts in Psychotherapy; 34, 340-349. Lawlor, D. A., & Hopker, S. W. (2001). The effectiveness of exercise as an intervention in the management of depression: systematic review and meta-regression analysis of randomized controlled trials. British Medical Journal.;322. Leach, M. (2006). Evidence-based practice: a framework for clinical practice and research design. International Journal of Nursing Practice; 12(5), 248-251 Leahy, R. (2010). The Cost of Depression. Available online; http://www.huffingtonpost.com/robert-leahy-phd/the-cost-of-depression_b_770805.html Luborsky, L., Rosenthal, R., Diguer, L., Andrusyna, T.P., Berman, J. S., Levitt, J. T., Seligman, D.A., & Krause, E.D. (2002). The dodo effect is alive and well – mostly. Clinical Psychology: Science and Practice; 9 (1), 2-12. Maratos, A., Gold, C., Wang, X., & Crawford. C. (2009). Music Therapy for Depression. Cochrane Database of Systematic Reviews 2008; Issue 1. Art. No: CD004517. DOI: 10.1002/14651858.CD004517.pub2. Mason, D. J., Leavitt, J. K., & Chaffee, M. W. (2002). Policy and politics in nursing and health care (4th Ed.). St Louis, MO: Saunders/Elsevier. Melnyk. B. M., & Fineout-Overholt, E. (2005). Making the case for evidence-based practice. Philadelphia: Lippincott Williams & Wilkins. Mead, Movely, & Campbell. (2008). Exercise for depression. Cochrane Database of Systematic Reviews; (4), CD004366 Medical News Today. (2005). Costs of Antidepressants Could Have Funded Effective Alternatives, UK. Available online; www.medicalnewstoday.com/articles/21465.php Meekums, B. (1999). A creative model for recovery from child sexual abuse trauma. The Arts in Psychotherapy; 26 (4), 247-259. Meekums, B. (2002). Dance Movement Therapy. London: Sage. Meekums, B. (2006) Embodiment in dance movement therapy training and practice. In: H. Payne (Ed.) Dance Movement Therapy: Theory, Research and Practice (pp 167-183), London: Routledge.

27

Meekums, B. (2010). Moving towards evidence for dance movement therapy; Robin Hood in dialogue with the king. The Arts in Psychotherapy; 37, 35-41. Meekums, B. Karkou V. Nundy-Mala, A, Elefant C and Nelson A (2010) Dance Movement Therapy for Depression. Cochrane Collaboration; Title accepted. National Institute for Clinical Excellence (NICE). (2009). Depression: the treatment and management of depression in adults. Retrieved 20 06 2011. Available online; http://www.nice.org.uk/nicemedia/pdf/Depression_Update_FULL_GUIDELINE.pdf National Institute of Mental Health (NIMH). (2006, last reviewed 2010). Questions and Answers about the NIMH Sequenced Treatment Alternatives to Relieve Depression (STAR*D) Study — Background. Available online; http://www.nimh.nih.gov/trials/practical/stard/backgroundstudy.shtml National Institute of Mental Health (NIMH), (2005). National Institute of Health Department of Health and Human Services FY 2005 Budget. Available online’ www.nimh.nih.gov/aboutbudget/cj2005.pdf Office of National Statistics. (2000). Psychiatric Morbidity Report among adults living in private households. Available online; www.statistics.gov.uk Payne. H, (2009). Pilot study to evaluate dance movement psychotherapy (the body mind approach), in patients with medically unexplained symptoms: participant and facilitator perceptions and a summary discussion. Body, Movement and Dance in Psychotherapy; Vol.4, No.2, 77-94. Ritter, M., & Low, K.G. (1996). Effects of dance/movement therapy; a meta-analysis. The Arts in Psychotherapy; 23, 249-269. Rohrict, F., & Priebe, S. (2006). The effect of Body Orientated psychological therapy on the negative symptoms of Schizophrenia: a randomized controlled trial. Psychological Nursing; 36(5), 669-678. Scottish Intercollegiate Guidelines Network (SIGN) (2010) Non-Pharmaceutical Management of Depression. Retrieved 20 06 2011. Available online; http://www.sign.ac.uk/guidelines/fulltext/114/index.html Scott, J., & Dickey, B. (2003). Editorial: Global burden of depression: the intersection of culture and medicine. The British Journal of Psychiatry; 183, 92 – 94. Sjosten, N., & Kivela, S. L. (2005). The effects of physical exercise on depressive symptoms among the aged: a systematic review. International Journal of Geriatric Psychiatry; 21(2), 410-418.

28

Steward, N. J., McMullen, L. M., & Rubin, L, D. (1994). Movement Therapy with depressed inpatients: a randomized multiple single case design. Archive of Psychiatric Nursing; VIII (1), pp 22-29. Stiles, W. B., Barkham, M., Mellor-Clark. J., & Connell. J. (2007). Effectiveness of cognitive-behavioral, person-centered, psychodynamic therapies in UK primary-care routine practice: replication in a larger sample. Psychological Medicine; 38, 677-688. Sundararman, R. (2009). The U.S Mental Health Delivery System Infrastructure: A Primer. Congressional Research Service 7-5700, R40536. Available online; www.crs.gov The Center for Economic Performance’s Mental Health Policy Group. (2006). The Depression Report: a new deal for depression and anxiety disorders. Retrieved 20 06 2011. Available online; http://cep.lse.ac.uk/textonly/research/mentalhealth/DEPRESSION_REPORT_LAYARD.pdf The Department of Health (2008). Improving Access to Psychological Therapies (IAPT); Long-term Conditions Positive Practice Guide. Available online; www.dh.gov.uk/publications The Scottish Government (2008). Heat Targets for Psychological Therapies. Retrieved 20 06 2011. Available online; www.scotland.gov.uk U.S Department of Health and Human Services (2011). Available online; http://www.hhs.gov/ Vaverniece, I., Dusele, I., & Meekums, B. (in preparation). Dance movement therapy for obese women with emotional eating: a controlled pilot study Williams, L., & Tappen, R. M. (2007). Effect of exercise on mood in nursing home residents with Alzheimer’s disease. National Institute of Health, Public Access; PMC December 2007. World Health Organization. (WHO) (2010) Depression. Retrieved 20 06 2011. Available online; http://www.who.int/mental_health/management/depression/definition/en/ Wu, Shwu Ming., & I-Shou, U (2002). Effects of music therapy on anxiety, depression and self esteem of undergraduates. An International Journal of Psychology in the Orient; 45(2), 104-114 Xia, J., & Grant, T. J. (2009). Dance Therapy for Schizophrenia. Cochrane Database of Systematic Reviews; (I) ISSN: 1469-493. Zorumski, C., & Rubin, E. (2011) Demystifing Psychiatry. Psychology Today. Available online;

29

http://www.psychologytoday.com/blog/demystifying-psychiatry/201101/how-many-people-are-treated-depression

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Table A: The Search Strategy

Search Combinations Resources

Diagnosis: Depress* Interventions: D/MT Dance/Movement Therap* or Dance Movement Therap* or Dance Therap* or Dance Movement Psycho* or Movement Psychotherap* or Movement Therap* Arts Therapies Art* Therap* or Art* Psychotherap* or Dramatherap* or Drama Therap* or Drama Psychotherap* or Music Therap* or Music Psychotherap* Dance Dance* or Dance/Movement Research Design Randomi* or Controlled Trial* or RCT* or Experiment* Combinations Diagnosis and D/MT Diagnosis and Arts Therapies and Research Design Diagnosis and Dance and Research Design

General journal databases for Psychology and life sciences, to be accessed through Applied Social Science Index & Abstracts British educational index British humanities Index British Nursing Index CENAHL CINAHL EThOs ERIC IBSS International Bibliography of the Social Sciences Igenda Journals@Ovid PILOTS PubMed PsycINFO SALSER SCOPUS Shine Union List SSCI Social Sciences Citations Index Zetoc Search EBSCO Host Specific databases Springerlink Informaworld Sciencedirect Wiley Interscience Ingentaconnect SAGE JSTOR MEDLINE/PubMed Web of knowledge British Nursing Index All EBM reviews Hand Searches European Network for the Professional Development of Dance Movement Therapy Association for Dance Movement Psychotherapy UK

31

American Dance Therapy Association Dance-Movement Therapy Association of Australia German Research Register

Table B: Example of Literature Searches

Journal or other database Database, Journal or Grey Literature

Date Diagnosis Intervention Research Design

Total Articles Found

Relevant Articles Found

EBSCO Host (inc PsycINFO, MEDLINE, CINAHL)

11/10 Depress* Dance Movement Therap* or Dance Therap* or Dance Movement Psycho* or Dance/Movement Therap* or Movement Psychotherap* or Movement Therap*

- 64 Koch et al 2007 Jeong et al 2005 Payne 2010 Stewart et al 1994 Brooks and Stark 1989 Harden 1989

EBSCO Host (inc PsycINFO, MEDLINE, CINAHL)

11/10 Depress* Art* Therap* or Art* Psychotherap* or Dramatherap* or Drama Therap* or Drama Psychotherap* or Music Therap* or Music Psychotherap*

Randomi* or Controlled Trial* or RCT* or Experiment*

74 Stewart et al 1994 Wu 2002 Erkkila et al 2008

EBSCO Host (inc PsycINFO,

11/10 Depress* Dance* or Dance/Movement

Randomi* or Controlled

28 Jeon et al 2005 Koch et al

32

MEDLINE, CINAHL)

Trial* or RCT* or Experiment*

2007 Alpert et al 2009

Hand Searches

11/10 German Research Register 1 Brauninger 2006

Table C: Findings

Studies on dance and specific D/MT aspects for clients faced with depression

1. Eyigor, S. Karapolat, H. Durmaz, B. Ibisoglu, U. Cakir, S. (2009). A randomized controlled of Turkish Folklore dance on the physical performance, balance, depression and quality of life in older women.

2. Koch, S. Morlinghaus, K. Fuchs, T. (2007). The joy of dance: specific effects of a single dance intervention on psychiatric patients with depression.

3. Alpert et al (2009) The effects of modified jazz dance on balance, cognition and mood in older adults.

4. Jeon et al (2009) Effects of a Korean traditional dance movement program in elderly women.

Studies on Arts Therapies for clients faced with depression

5. Erkkila, J et al (2008) The effect of improvisational music therapy on treatment of depression; protocol for a randomized controlled trial.

6. Wu, Shwu Ming, I-Shou U, (2002) Effects of MT on anxiety, depression and self-esteem of undergraduates

Studies on D/MT for clients faced with depression

7. Jeong, Y, J. Hong, S, C. Lee, M, S. Park, M. (2005). Dance Movement Therapy improves emotional responses and modulates neurohormones in adolescents with mild depression.

8. Steward, N, J. McMullen, L, M. Rubin, L, D. (1994). Movement Therapy with depressed inpatients; a randomized multiple single case design.

9. Harden (1989) Effect of movement group therapy on depression, morale and self- esteem in aged women